HomeMy WebLinkAbout1569A WORKERS'COMPENSATION DECLARATION I I L I IT
I hereby affirm fhat I have a certifimte of consenf to self 20-0026 DPW 6/87
insure, or a certificaie of Workers' Compensalion Insurance, 76A667A
or a certified copy thereof (Sec. 3800, lab. C.) COUNTY OF LOS ANGELES DEPT. OF PU�LIC WORI<S
Policy No.�'�+�J�f7-�9�Company c������� ✓�,
� ���� ����� ��
� Certified copy is hereby furnished. �s
� FOR APPLICANT TO Fill IN(PRINT OR TYPE) ADDRESS � e,,,,,J� , �
Certified copy is filed with the couMy building inspec- � '� �� ` �� ���
tion deppriment. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
�/r'�y'�'1 d A�' �/'--�.-e�.
Date � � Appli4ant WATER CLOSET NEAREST �j
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.��f}'D�U� �`�i� `t1�i 5� �/�A.�J�I
COMPENSATIONINSURANCE SHOWER �WNFk�7�J"1�i ��1��/f�- �.���:�.
(Thli�action ne�d net ba eompl�f�d if tha wark Involved by MAIL a�1
1h�psrmit le for ono hundr�d dollar: ($100) e�e le�s,) LAVATORY ADDRESS�����/ iT/�t�f�� �L�� `��: /l!�
I cerfify fhat in the performance of the work for which this ,�y
ermit fs issuad, I shall not am lo an erson in an mannor SINK GTY TEL. NO
P p Y Y P Y <-������- /���/�' '�!<J�r�°�-��te/
so as to become subject to the Workers'Compensation Laws, DISHWASHER -s-
CONTRACTqR���/���p ���.����f����� ��I�
Date Applicant CLOTHES�NASHER +�G.
ADDRESS � � �y� ���j�
NOTICE TO APPLICANT; If, after making this Certificate ot �.
mption, you should become sub�ect to the Workers' SWIMMING POOL RECEPTOR �--�
mpensation provisions of ihe Labor Code, you must forfh- � �AWNSPRINKLERSYSTEM � CIFY �c 9 7��L.�l�� TEL, NO �t� ��>���
wHh comply wifh such provlsions or this permit shal) be STATE LIC. r�
deemed revoked, WATER HEATER LICENSE NO.��C'' �'�� � CLASSG '� /
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PRO SSED BY
I hereby affirm that I am Ilcensed under provisions of Chapter 9 GAS SYSTEM oUTIETs � `� �
(commencing with Section 7000) of Diaision 3 of fhe Business OUTLETS OVER '� `� `���'"��
and Professions Code,and my license Is in full force and effect. 5 PER SYSTEM FINAL \/�►dB�ATOO(d
�7 �� r DATE
License Number �-'J���'`��" Lic. Class `��
���� FINAL
Confracto���,���y ����c��'� Date '� � BY
❑ I am e�f�"nder SeE"���� ?����
B.&P.C. for this reason p�an check fee
Date: PLUMBING PERMIT ISSUING FEE$ �"�
Signature
�f� ✓
TOTAL FEE � ��
Plan check applicant �
SINGLE FAMILY
HOME OWNER-BUIIDER DECLARATION Name
�reby affirm fhat I am exempt from fhe CoMractor's License
for the following reason (Section 7031.5, Business and Address j . „ � �
Professions Code): City Tel. No.
❑ I, as owner of the property, will do the work and fhe
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm fhat ihere is a construdion lending agency for
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that I have read this application and state that ihe
above information is correct. I agree to comply with all County
ances and State laws regulating Plumbing, and hereby
�uthori e repre°sentatives of fhis Counfy to enter upon the
� above- entione ro riy for inspection purpo es.
'�'°. r SEE REVERSE FOR E3(PL�.NATORY LAP1C911.4GE
rt�� �':�,��.�.�. `� o i ���
Sign ture of Permitt Date